Manuel Garcia, MD, Esther Wu, MD, Robert F Cubas, MD, Daniel P Srikureja, MD, Kaushik Mukherjee, MD, MSCI, FACS. Loma Linda University Medical Center
Introduction: Morgagni hernia is a relatively uncommon anterior diaphragmatic hernia, particularly in adults. Open, laparoscopic, and thoracoscopic approaches have been described in both adults and children. Only three cases have been reported using robotic techniques in adults. We present the case of a patient who presented urgently due to signs and symptoms of a bowel obstruction from an incarcerated Morgagni hernia and was repaired after admission to the Acute Care Surgery service at a tertiary care center.
Case: The patient is a 29 year old morbidly obese male with a body mass index of 55 kg/m2. He had a previous history of epigastric abdominal pain, nausea, and vomiting. He had failed a prior attempt to schedule elective repair due to changes in insurance. The patient presented to the emergency department with signs and symptoms of a bowel obstruction. CT scan revealed gastric distention and the previously visualized Morgagni hernia with incarcerated distal stomach, duodenum, and transverse colon. The patient was managed with nasogastric tube decompression and taken to the operating room for robotic repair. Standard port placement was used for esophageal cases on a DaVinci Xi system (Intuitive Surgical Inc., Sunnyvale, CA). Using atraumatic graspers, we reduced the incarcerated omentum, colon, stomach, and duodenum into the abdominal cavity. There was omentum and distal stomach tightly adherent to the anterior and medial surfaces of the pericardium and the pleura. Once this tissue was lysed the remainder of the incarcerated contents easily reduced. The 10 x 5 cm anterior diaphragmatic defect would not approximate due to tension. We therefore interposed a composite mesh cut to 20 x 15 cm and used permanent suture in an interrupted fashion to affix the mesh to the edges of the defect. Anteriorly we used a trans-fascial suturing device. We used an absorbable tacking device to reinforce the attachment circumferentially. We sutured two remaining areas of laxity with barbed absorbable suture. Operative time was 259 minutes. The patient was discharged from the hospital on postoperative day #5 and has done well at followup.
Discussion: Robotic surgery, in the hands of appropriately trained acute care surgeons, may offer the chance to apply minimally invasive techniques even for urgent surgical care. This is the first reported case of an incarcerated Morgagni hernia repaired urgently using robotic techniques, and the first case performed by acute care surgeons.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87436
Program Number: V126
Presentation Session: Friday Exhibit Hall Theater (Non CME)
Presentation Type: EHVideo